Rhino-sinusitis: inflammation of lining mucosa of nose & paranasal sinuses Acute: infection lasting < 4 weeks Sub acute: infection lasting 4 to 12 weeks Chronic: infection lasting > 12 weeks Recurrent acute (RARS): > 4 episodes in a year, each episode lasting for 7-10 days, without persistent symptoms in between Etiology: Rhinogenic: commonest (85%), following any form of rhinitis Dental: root abscess, dental procedures (maxillary sinusitis) Trauma: Accidental: R.T.A., swimming, diving, F.B., barotrauma Iatrogenic: nasal packing, septal surgery Hematogenous : rare Symptoms Nasal discharge : mucoid / purulent / blood-stained Nasal obstruction with hyposmia / anosmia Headache and facial pain Cheek / eyelid congestion and swelling Hawking, sore throat, dry irritating cough Earache: associated Eustachian tube dysfunction Constitutional: fever, malaise, body ache Rhinosinusitis Task Force Criteria (RI 2004) Location of facial pain in sinusitis Maxillary sinusitis Cheek, upper jaw, forehead that increases on bending forward Frontal sinusitis Pain over the forehead that increases during morning and decreases by late afternoon (office headache) Anterior Ethmoid : nasal bridge and peri-orbital, more on eye movement Posterior Ethmoid : deep seated retro-orbital Sphenoid : vertex, occipital, retro-orbital pain Palpation to elicit paranasal sinus tenderness Maxillary: over the canine fossa Anterior ethmoid: medial to medial canthus Frontal: Floor of sinus at the superomedial aspect of the orbit or tap over its anterior wall on the forehead Postural tests for rhinosinusitis Performed in acute sinusitis (active nasal discharge) Pus cleaned in supine position & patient sits upright Pus appears : frontal or ethmoid sinusitis Pus appears on stooping forwards: sphenoid sinusitis No discharge  patient lies in lateral position with affected side up Pus appears: maxillary sinusitis Plain x ray of Paranasal Sinuses Water’s view (Occipito -mental) maxillary sinus Caldwell’s view (Occipito -frontal) and lateral view frontal Rhese’s view (lateral oblique) and laterai view  ethmoids Base skull view (Submento - vertical) and Pierre’s view (Occipito -mental with mouth open)  sphenoid Air-fluid level seen in acute sinusitis Mucosal thickening seen in chronic sinusitis CT scan of nose and PNS Most reliable imaging modality for sinusitis at present Plain axial, coronal and sagittal cuts of 3 mm (contrast for suspected vascular, neoplastic, inflammatory lesions) Helps to delineate the extent of disease, define anatomical variants and study the relationship of sinuses with surrounding  structures Indications: Recurrent acute/chronic sinusitis not responding to medical treatment Before endoscopic sinus surgery Impending complications of sinusitis

1. Rhinosinusitis:
Definition, Clinical features and Diagnosis
Dr. Krishna Koirala
2023-07-25

2. • Rhino-sinusitis: inflammation of lining mucosa of nose &
paranasal sinuses
• Acute: infection lasting < 4 weeks
• Sub acute: infection lasting 4 to 12 weeks
• Chronic: infection lasting > 12 weeks
• Recurrent acute (RARS): > 4 episodes in a year, each episode
lasting for 7-10 days, without persistent symptoms in between
Definitions

3. Types of sinusitis
• Acute / sub acute / chronic / recurrent
• Open / Closed (depending on its drainage)
• Unilateral / bilateral
• Maxillary / frontal / ethmoidal / sphenoidal
• Single / multi / pan-sinusitis
• Anterior / posterior group
• Suppurative / hypertrophic
• Bacterial / fungal / allergic / occupational

4. Etiology
• Rhinogenic: commonest (85%), following any form of rhinitis
• Dental: root abscess, dental procedures (maxillary sinusitis)
• Trauma:
– Accidental: R.T.A., swimming, diving, F.B., barotrauma
– Iatrogenic: nasal packing, septal surgery
• Hematogenous : rare

5. • Mucosal edema: viral, bacterial, allergic, irritant, vasomotor,
barotrauma
• Mechanical obstruction:
− DNS with spur, polyp, hypertrophied turbinate
− OMC anomalies: concha bullosa, paradoxical middle turbinate, Haller cell,
large bulla ethmoidalis, agger nasi, uncinate anomaly
− Nasal tumours, foreign body, nasal packing
Predisposing factors

6. • Mucous abnormality and Mucociliary dysfunction
−Young’s syndrome, Kartagener’s syndrome, cystic fibrosis,
excessive cold and dry climate, allergy, hypoxia, smoking
• Miscellaneous:
−Poor health, immunodeficiency, diabetes, nutritional deficiency,
i.v. drug abuse

9. Bacteriology
• Acute sinusitis
− Streptococcus pneumoniae
− Hemophilus influenzae
− Moraxella catarrhalis
− Staphylococcus aureus
− Neisseria
• Chronic sinusitis
−Staph. aureus
−Streptococcus
−H. influenzae
−Bacteroides
−Pseudomonas

10. • Severity and resolution depends on
–Open / closed
–Virulence of the organism
–Host resistance
–Treatment received

11. • Ostio-meatal complex is key area for
causation of infection in anterior group
of sinuses
• Pathological variants of ostio - meatal
complex play a major role in causation
of sinusitis due to reduced ventilation
and drainage of sinuses

12. Clinical features of Rhinosinusitis
• Symptoms
− Nasal discharge : mucoid / purulent / blood-stained
− Nasal obstruction with hyposmia / anosmia
− Headache and facial pain
− Cheek / eyelid congestion and swelling
− Hawking, sore throat, dry irritating cough
− Earache: associated Eustachian tube dysfunction
− Constitutional: fever, malaise, body ache

13. Rhinosinusitis Task Force Criteria (RI 2004)
Major Minor
1. Facial pain / pressure 1. Headache
2. Nasal obstruction 2. Fever (non-acute sinusitis)
3. Nasal discharge or 3. Halitosis
discolored postnasal drip 4. Fatigue
4. Hyposmia / anosmia 5. Dental pain
5. Purulence on exam 6. Cough
6. Fever (acute sinusitis) 7. Ear pain / pressure / fullness
Presence of 2 major factors or 1 major + 2 minor factors = sinusitis

14. Location of facial pain in Rhinosinusitis
• Maxillary sinusitis
− Cheek, upper jaw, forehead that increases on bending forward
• Frontal sinusitis
− Pain over the forehead that increases during morning and decreases
by late afternoon (office headache)
• Anterior Ethmoid : nasal bridge and peri-orbital, more on eye
movement
• Posterior Ethmoid : deep seated retro-orbital
• Sphenoid : vertex, occipital, retro-orbital pain

15. Signs of Rhinosinusitis
• Cheek swelling in maxillary sinusitis
• Lid edema in ethmoid & frontal sinusitis
• Congested and edematous nasal mucosa
• Nasal discharge
−Middle meatus: frontal, maxillary, anterior ethmoid
−Superior meatus: posterior ethmoid, sphenoid
• Tenderness over the paranasal sinuses
• Postnasal drip, granular pharyngitis

16. Palpation to elicit paranasal sinus tenderness
• Maxillary: over the canine fossa
• Anterior ethmoid: medial to medial
canthus
• Frontal: Floor of sinus at the
superomedial aspect of the orbit or tap
over its anterior wall on the forehead

18. Transillumination test for sinuses
• Performed in a dark room
• High-intensity light source placed inside patient’s mouth
or against the cheek (for maxillary sinus) & under medial
aspect of supra-orbital ridge (for frontal sinus)
• Trans-illumination normal : no sinusitis
• Trans-illumination absent : sinus filled with pus
• Trans-illumination dull : equivocal result

19. Postural tests for sinusitis
• Performed in acute sinusitis (active nasal discharge)
• Pus cleaned in supine position & patient sits upright
• Pus appears : frontal or ethmoid sinusitis
• Pus appears on stooping forwards: sphenoid sinusitis
• No discharge  patient lies in lateral position with affected side up
• Pus appears: maxillary sinusitis

20. Investigations
1. Diagnostic nasal endoscopy (D.N.E.)
2. Maxillary Sinoscopy
3. X-ray of P.N.S.
4. U.S.G. of maxillary sinus (Rhinoscan)
5. C.T. scan of P.N.S.
6. M.R.I. of P.N.S.: rarely done
7. Allergic tests
8. Proof puncture (antral wash): for maxillary sinus
9. Endoscopic microswab for culture & sensitivity
10. Fungal culture: of cheesy nasal discharge

21. Diagnostic Nasal Endoscopy

22. • Patients not responding to medical therapy
• Anatomic factor preventing adequate
examination by anterior rhinoscopy
• Collection of pus from hiatus semilunaris for
culture & sensitivity
• Objective monitoring of patients
• Peri-operative nasal inspection & cleaning
Indications for D.N.E.
Pus seen in middle meatus
on doing D.N.E.

23. Maxillary sinuscopy
• Anterior sinus wall perforated directly
through canine fossa between roots of
3rd & 4th teeth with maxillary sinus
trocar & cannula
• Trocar removed and sinoscope
introduced through cannula to look
inside the maxillary sinus

24. Plain X- ray of Paranasal sinuses
• Water’s view (Occipito -mental)  maxillary sinus
• Caldwell’s view (Occipito -frontal) and lateral
view frontal
• Rhese’s view (lateral oblique) and laterai view 
ethmoids
• Base skull view (Submento - vertical) and Pierre’s
view (Occipito -mental with mouth open) 
sphenoid
− Air-fluid level seen in acute sinusitis
− Mucosal thickening seen in chronic sinusitis

25. Para-nasal sinus sonography
• Bony anterior wall is seen as hyper-echoic line
• Maxillary cavity filled with air appears as hyper-
echoic hence posterior sinus margin not seen
• Fluid in sinus, cyst & mucosal thickening are
hypoechoic, so posterior sinus margin is visible
• B mode sonogram differentiates between fluid
in sinus, cyst & mucosal thickening

26. C.T. scan of Nose and PNS
• Most reliable imaging modality for sinusitis at present
• Plain axial, coronal and sagittal cuts of 3 mm (contrast for suspected
vascular, neoplastic, inflammatory lesions)
• Helps to delineate the extent of disease, define anatomical variants and
study the relationship of sinuses with surrounding structures
• Indications:
• Recurrent acute/chronic sinusitis not responding to medical treatment
• Before endoscopic sinus surgery
• Impending complications of sinusitis

28. M.R.I. of P.N.S.
• Indications
−To assess the intracranial extension of
sinonasal disease, brain abscess due to
sinusitis and meningocele or encephalocele
−To evaluate the orbital complications of
sinusitis
−Malignant neoplasms of sinonasal tract